Individual
TREVOR DEWITT WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
571 EVA KENNEDY RD APT 8, SUWANEE, GA 30024-3008
(770) 369-1497
Mailing address
571 EVA KENNEDY RD APT 8, SUWANEE, GA 30024-3008
(770) 369-1497
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
—
—
Other
Enumeration date
07/20/2017
Last updated
07/21/2022
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